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Thursday, November 28, 2013

Thankful that my two oldest are at their grandmother's being stuffed with carrot cake and turkey and steak and love. Thankful my mom and sister will be together in the snowy mountains of West Virginia. Thankful that our Paeds team gathered 40-plus-strong with visitors and kids to feast together, a taste of the Kingdom, shared struggle against suffering, shared victories, shared love. Thankful that Patrick's sister got him up into a chair and spent the day reading through Genesis aloud. They were on chapter 9 last time I saw them. Thankful that my patients made it through today and I have a weekend off. Thankful that the home-front-kids finished exams for the term and we can celebrate with them and Miss Bethany this weekend. Thankful for almost 50 pounds of turkey on the grill, and more mashed potatoes than a human army could eat. Thankful for colleagues, particularly the young Kenyans pictured above, and even my colleague with preterm labor who is calmly emerging from the danger zone. Thankful for this reminder on the true nature of Thanksgiving:

"One act of Thanksgiving made when things go wrong is worth a thousand when things go well." St. John of the Cross

Wednesday, November 27, 2013

Some are trivial. My swollen not-broken toe is annoying. But, it slows me down to walk Kenyan-paced. I'm no longer zipping past people in the halls. I have more time between places to think. I have more time in general because I'm not exercising at all. Which is not so mentally or physically healthy, but I think I needed that margin this week.

Or the fact that half my family is in a time zone 11 hours off. So when I was wiped out post-call and the three kids here were all in late evening study groups and Scott was also occupied, I could call them. Nice. Sometimes 11 hours is easier than 7 or 8.

A big one this week is that Scott is finally getting administrative time. So even though I feel even more behind on many things and tempted towards jealousy, it is HUGE to have a functional parent. He is making phone calls to teams, working on our legal/immigration issues in Kenya, going to meetings, and even wrote our December prayer letter which is shockingly the only one this year. It's been one of those years. And a nice perk is that he made dinner the last two nights.

I had been in the hospital this morning for over an hour with a visiting cardiologist seeing patients when I was called emergently to the Annex. A neurosurgical patient on whom we had consulted for the last week had been found pulseless, milk vomited all over his face. He was not just temporarily arrested. He was dead for at least 10 or 15 minutes, which his mother had not recognized, getting an extra blanket in response to his coldness. I intubated him and gave him drugs while we did CPR as a team, but no response. Bagging air in and out, needles, syringes, suggestions, checking anxiously, more drugs, more chest pumping, more time. It wasn't working. Finally the reluctant halt, the lifelss reality. A prayer. Not sure where the silver lining is here. His mother was hysterical, disbelieving, shaking. His dad was sober, then weeping. I am sad, and feel defeated, or perhaps cheated. He was getting better. We had not expected this sudden death. I am going over the scenario this evening in my heart, over and over, looking for answers.

And that is legitimate too. Lament is lament. The silver lining is too subtle, too tarnished, for me to see with this child. I was reminded in reading a friend's blog about Jonah that lament is an expression of faith. The world is not as it should be. Sometimes we can see a glimpse of redemption in the suffering, a silver lining. But sometimes we can not, but we hold on in faith to the evidence of unseen sparkle.

Monday, November 25, 2013

A couple of nights ago I dropped my computer, corner down, directly onto my foot as I was trying to balance several things and get under the mosquito net and plug it in on my bedside table at night. I'm pretty uncoordinated, it was the end of a hard day, and in spite of the word "air" in the name, when dropped from a height onto the unsuspecting toe, it can do damage. It hurt. BADLY. I cried like I haven't in some time. The next day my toe was purple, and the day after about a tangerine-sized bruise was fanning out on my foot. It hurt to walk. I wondered if it could be broken, but at least the computer worked fine, and frankly it is easier to heal a toe than replace a computer here. So I hobbled all weekend, on my feet doing Senior Store and walking back and forth and cooking. Today back at work, I kept looking for a few minutes between too many colliding responsibilities to get my own health care.

So let me sing the praises of being at Kijabe Hospital. It was 12:38. I had a meeting at 1:00 and labs to check and phone calls to make and perhaps one more patient to see. I checked in with nursery where I was waiting for a 25 week preemie to be born. Not yet. As I walked down the hall I decided to just get an xray because there was miracle-of-miracles NO LINE. I had a form in my pocket, and filled it out as I stood at the cashier's window and made pleasant conversation, writing in my own diagnosis. Before I could look up my medical record # he had it on his computer. Price: 30 bob please. That's less than 50 cents. I guess my toe is small. I took my receipt across the hall where the xray techs were having tea. I chatted with them and one jumped up to take my xray. They were quite entertained. She warned me not to walk barefoot where the last patient had been bleeding . . . an awkward position, a charge and a beep and I was out. While they processed the film I went back over to lab to follow up on some results for my patients. Back across the hall and the techs declared I had not fracture, but I carried the film a few steps away and showed it to a visiting radiologist. Normal, just soft tissue swelling.

Total time: 15 minutes. Total cost: less than a dollar. Total cure: none. That's the only down side, my foot still aches and I'm still limping. But my computer works and hopefully each day will get a little better.

In a day which included: calling my boys in California, rounding on my service, seeing a missionary baby and connecting the family with specialist care, getting another missionary kid discharged post-surgery, being called to the delivery of a 25-week baby whose fused eyes and transparent skin made her look even younger, and deciding to stop the resuscitation because she was not viable (weighty and sad), waiting for ANOTHER 25 week baby who is still not born, running up to RVA to applaud Acacia's induction into the National Honor Society (!), evaluating admissions, going to an early staff prayer meeting and a lunch-time Moms prayer meeting and having an evening WHM conference call and just generally surviving . . . This little pocket of efficiency was very encouraging.

And the other happy moment: About 4 pm I was comforting the mom of the too-early-to-survive preemie and got an emergency call to ICU. Patrick, the 11 year old with Guillan-Barre induced paralysis, had extubated. Since he's pretty inactive it couldn't be blamed on him, but somehow in the process of suctioning and turning him the tube was gone. I had seen in the morning that he was moving his legs a bit as he tried to talk around the tube to me. So as I ran up I thought we would give him a chance to see if he could breathe. It had been a week on the ventilator. I had expected longer before he began to improve, but so many were praying, maybe he would be OK. I examined him and talked to others and asked him if he felt he could try to breathe, and he nodded. Then he was trying to talk and we all leaned in to hear what he was saying. "Jennifer". He was talking to me. I guess he had read my nametag and heard me introduce myself. You have to realize most of my patients are less than a year old and don't speak English. Having an 11 year old say my name as the first words out of his mouth in the ICU was sort of sweet and sort of chilling. It is now 10:30 pm and he's holding his own for now.

A cheap quick xray with no fracture and an unexpected turn for the better. Against a background of struggle, two bright spots (plus Acacia and friends to pray with) for today.

Sunday, November 24, 2013

Julia decided she wanted to be baptized at RVA, to publicly declare her faith in the context of this quite Baptist culture. Even though all our kids were baptized as infants in the Presbyterian church, we have maintained that God would not mind if they chose to repeat that sacrament as mature believers. She was one of 9 kids who went through classes with the pastor this term. Each gave a testimony of faith in their own words, then had one or two siblings or friends read favorite Bible verses aloud. Julia chose Zeph 3:17 and Gal 2:20, read by Jack and Acacia.

Julia's testimony declared that she wants to live for God's glory and spread His name throughout the earth wherever He will lead. She said she desired to have one pure passion for Christ above all else, dedicating every breath and every heartbeat back to Him forever.

In the baptism pool each baptizer said some other words from Scripture. Scott spoke about the symbolism of death and resurrection and the way all of creation is being redeemed and renewed by the Gospel, and how this baptism signals Julia's participation in God's work.

I prayed for her as her friend Savvy wrapped her in a towel, and mentor/teacher/friend Bethany gave a benediction. This is a place where we see the beauty of a community who helps us raise our children, truly a group project.

Here is the prayer, please read it prayerfully for Julia today:God our Father, Jesus our Lord and Saviour, and Holy Spirit our Helper, We give your Name glory today as we witness the life and testimony of Julia.

We ask that your Kingdom would come more fully to this earth through her life, and that you would bless your people and your creation through her, that you would so fill her with love that she would be a source of water for the thirsty and healing for the hurting. May the word of her testimony and the abandon of her life in love be your instruments for transformation in this broken, beautiful world.

May your will be done in her life as it is in Heaven, bringing her the peace of your reign, growing her in wisdom and in stature and in favor with God and man. May she ever be a tree planted by rivers of Living Water, fruitful and enduring in her faith.Give her every day her daily bread, your physical provision and your sustaining word and presence. .

Forgive her when she falls short of your best for her, and give her a generous spirit to forgive others

Protect her in all her paths as she walks with courage and grace into a needy world, give her solid community and life-long friends, and deliver her from the Evil One. When your ways are hard may she say "Let it be unto me according to your word." Assure her of your goodness all the days of her life.

Lord we thank you for Julia from the deepest part of our hearts and pray she would be a jewel in your crown.Now to Him who is able to keep Julia from stumbling, And to present her faultless before the presence of His glory with exceeding Joy,To God our Saviour who alone is wise, Be glory and majesty, dominion and power,Both now and forever. Amen.

This is the stuff of Angel parties, the behold-I-am-well-pleased of God Himself. And a reminder that all the other stuff, the late nights and early mornings and sorrowful stories and sweat and tears, pales in comparison. So thankful for this daughter and all our kids.

Friday, November 22, 2013

It's been another one of those weeks. Last night as I held the sobbing mother of the fourth child I'd pronounced dead in a week, holding her hand, preaching, praying, aiming for firm compassion and sympathetic truth, I was spent. I came home profoundly exhausted. For me failure and rejection look like stiff grey dead babies, or the tense juggling of too few hands for too much work as another issue arises that means someone has to go. For some people dear to my heart, it looks like this: a limbo of not-yet-picked in the too-slow med school app process in spite of a near-perfect gpa at an ivy league school, a rejection for one of two summer programs in spite of being top 5% of class in an elite military academy, the SAT debacle and waiting to hear from colleges, being cut from a sports team early this term, and lastly being rejected by staff in an application for national honor society in spite of grades and activities and service. Yeah, that's kids 1 to 5 lately.

So in case that rings true for others, here are the garden thoughts of today.

1. It's not all about me, but God's glory. My failure or rejection is a small subplot in a very large story that centers on bigger things. Like the redemption of the world. When Lazarus' sisters and friends said "If you had been here our brother would not have died" (a line that was unintentionally quoted pretty much verbatim to me after a death this week) they didn't know the bigger good that would come, for the glory of God (John 11). I read this on a friend's blog "we must seek to cultivate a mindset that will not accept the suffering, injustice, oppression, idolatry, sin, selfishness, materialism, brokenness, sorrow, misery hopelessness, bondage, apathy, compromise, division, sorrow, … that we should not accept this world in its fallenness as natural, normal or inevitable. Passionate, persistent intercessory kingdom prayer dies when God’s people become insensitive or reconciled to the fallen world’s status quo. We saw we must nurture a proper faith perspective about our Father in heaven. " That puts life back in perspective. There are important battles being fought, and I can't see yet how it all fits together and makes cross-perspective sense.

2. Your loss is likely someone else's gain. In this world, not everyone can get into their choice of school or society. There are quotas, and if you lose, then the spot goes to someone who might need it more. Whenever I think of my colleague's baby NOT being born preterm I am GLAD to do some extra work. Grace is infinite and God does not have to choose favorites, but in this world, zero-sum still prevails. (Rom 8:36)

3. There are usually kernels of truth in even the hardest rejections. When that 4th baby died, I presented the case to my expert Dr. Erika who was generally reassuring but also had some teaching points. Try to look through the sense of injustice to find ways to accept criticism and grow. We learn through loss, we grow when we come up against the scourging of life. Even Jesus did (Heb 5:8; 12:3-7).

4. Seize the opportunity to do good. Literally, to those that have hurt you. I am not good at this, I would rather punish them. But smile, shake hands, and don't let them get you down. Look for ways to actually serve them and make their life better. This makes no sense, but Jesus told us to do it Matt 5:44-45. I have actually tried it in small ways, and it is more powerful in changing MY attitude than anything else. But it also might lead to breakthroughs in the hearts of others. This is where the Kingdom shines.

5. Embrace the cross. Jesus was despised and rejected (Is 53:3). We're not living in a popularity contest. The rubber meets the road when you take up your cross after a man who was willing to take some heat and not change. Yes, rejection and failure usually help us learn something important for growth. But sometimes they are just part of being in the path of evil, of living in a fallen world, of other peoples' problems. I like to make people happy, and keep people alive. But (see #1) there are times when we have to hold on to our calling, to love, to work hard, and to not worry about what other people think.

6. And last but not least, remember love. Being loved, and giving love. The absolute truth about us is that we are created uniquely gifted to reflect some aspect of God's truth. God saw all that he had made, and it was very good . . our kids' first Bible memory verse from Genesis 1. Sin has marred each of us, but fundamentally the deepest truth is love. We are loved by God. My five great people are loved by me, and when push comes to shove I prefer them to anyone else I know in a tough spot--they are loyal, strong, creative thinkers, tireless workers, with a clever sense of humor and an eye for irony. They are the kind of people whom you want beside you when you're fighting a war, having a baby, cooking a meal, building a camp, living the Gospel.

7. Bonus, because 7 is a Biblical number: spend more time with dogs than people for a day, and everything looks better. Which relates to #6, because dogs help ground you in the reality of God's unconditional love.

Monday, November 18, 2013

Beginning on Friday night when I got a quick panic call during dinner and ended up running into the hospital to admit a little girl to the ICU after brain surgery, up until 5 pm Monday when I walked out the door after work, it has been a harrowing weekend. Nonstop, in a way that is unusual even for here.

Saturday morning rounds were still in their chaos of pending labs and confusing stories when I got the page to the operating theatre where 26-week twins were being delivered by C-section to save the life of their mother, who was dangerously ill, as well as their own lives. We knew ahead of time they were identical boys sharing the same placenta and sac. One was very small and sickly, only 530 grams. The other had more than his share of the blood supply, and came out ruddy and relatively vigorous at 950 grams. Thankfully the appendicitis colleague had not quite gone home so his wife who was waiting for his discharge agreed to run down and be an extra set of hands with these fragile twin boys for a while that morning. We dried and resuscitated, intubated and gave surfactant, a medicine to help coat the immature lungs and make up for their difficulties. I set up a little surgical area and inserted lines into both, then did something I've never done: took blood from the baby with too much, and gave it to his brother with too little. I spent most of the day fighting for their lives. This was the mom's first pregnancy. 26 weeks is rarely survivable in Africa, even with our best care, the prognosis was not good. 530 grams is smaller than we have ever had a survivor. And the prenatal ultrasound was suggestive that the smaller brother had some congenital anomalies.

After the second dose of surfactant, as I felt I was losing the battle, I got this xray (only by physically going and pushing the xray machine myself into the nursery). Almost no lung tissue seen. An hour later, this tiny twin died. The mom decided to name him "Success" and his brother "Blessing".

Who would call an 8 hour life for a tiny tiny baby a success? This struck me as a Kingdom paradox. In his mother's loving eyes, he was a success, simply by existing. Very sweet.

We pray his slightly larger brother, Blessing, will have a longer life, for the mom's sake.

It was an emotional weekend. Nonstop admissions, I lost count, but about a dozen including Friday night. Another teen with AIDS whose parents' denial and neglect meant he was starving. Neurosurgical patients with acute infections, malnourished toddlers, unexplained seizures, jaundice, more prematures. An 11 year old whose fear and sweet despair just got to my maternal heart (see below). I ran home a couple times to find my kids foraging leftovers from the fridge. Once on Sunday I managed to mix up pancakes, but they were pretty much on their own. The only half hour I spent out of the hospital from 8am to 11pm I found Julia making cookies:

These pretty much accounted for survival.

I had four babies who qualified by their lab values for exchange transfusions, an hours-long technical and risky procedure for severe jaundice. It took every ounce of courage and the Spirit to NOT do these transfusions and doubt the labs which seemed way worse than the babies looked. I held my breath to know whether I was doing harm or good, until today when the lab manager recalibrated and everyone's tests dropped back towards normal. Whew. I lamented missing RVA's play, but there was no way to leave.

By this morning, after a 2-3 am bedside vigil for two more deteriorating patients, I was pretty fried. There were some happy stories, like a 13 year old girl with diabetes who had moved from death to life, smiling and alert and looking great. I had about four patients well enough to go home, and was juggling their issues, 23 babies in nursery, 18 on the ward, one in casualty and one in private clinic, two in ICU, not to mention the outpatients just grouping. I would have been shot without rescue help from the inimitable Pete Halestrap, our ER doc who is spending three days to step in and lend a hand. That's another story, but I am so thankful for his cheerful can-do willingness. But when the little boy who had severe brain damage after a complication during surgical debridement at a local hospital last week of what should have been a simple, curable infection in his leg finally died, I was thankful to have the chaplain show up to help me comfort the mother. Then this afternoon the post-op brain tumor little girl, a 5 year old, also died. These and little twin A all had unsurvivable issues by the time they came to us. But 3 deaths in 2 days takes a toll. And as the father of the 5 year old said, straight out of the Gospels, "If only you had been there in August when this illness started, she would not have died." Meaning the entire hospital team, not me specifically. If only she had not been stuck with her resectable brain tumor for 3 months in a public hospital waiting for a surgical date. If only we could do more, for more people.

Which brings me back to the prayer for a largeness of heart.

In the midst of chaos and overwhelming patients and not only lack of doctor staff but on Saturday only half the needed nursing staff, I want to pray to become a person who exudes grace. When I told the 5-year-old brain tumor patient's father and aunt she had died, they did not hesitate. Their first words were, "Thank you for all you did." Thank you? She died! But they were able to look at me large heartedly, with grace, to be thankful. Amazing. In life's moments of harsh tragedy, I want a heart large enough to look beyond my loss, my exhaustion, my grief, to show kindness to others like these people did.

And when the next sad story comes into my responsibility, I want the largeness of heart to care. To feel the tears welling up in response to his own. To imagine my child in this position, to be willing to go the extra mile for cure.

To not give up, not close off. To hold onto hope, which becomes elusive, but is the only sure thing.

Image one day noticing some tingling fingers and toes, and then that you can't pick up firewood that you would normally gather, then a rapidly progressive weakness, then complete paralysis. Patrick is a bright articulate 11 year old who was a normal kid a week ago, and tonight is in the ICU on a ventilator because his breathing muscles are too weak to sustain his life. His symptoms and tests point to a diagnosis of Guillain-Barre Syndrome, a rare illness in which the body's own immune system attacks the nerve sheaths until the muscles have no impulse for movement. A once active boy over a matter of days has become a limp and helpless patient, without enough power to even breathe. But if we can keep him alive, the paralysis should recover, and he should slowly regain strength. Problem is, that might take weeks, or months. And staying alive on a ventilator, avoiding malfunctions and failure, escaping infection and sores and despair, in Kenya, is no small task.

Similar in some ways to my Dad's slowly progressive ALS, this is a disease that leaves the brain perfectly aware and intact as the body slips into a helpless passivity. So Patrick can talk to us, can ask for help, can listen, can cry. Saturday night as he panicked about his failing breath, I called Scott in to help me intubate him and put him on a ventilator. Today I told him with more conviction than I felt that he was going to recover, that this was temporary, that he would be out of the ICU within a month and playing football within a year. His tears of resignation and desperation as he looked at me pretty much made my sleep-deprived heart melt.

Would you pray for Patrick? Pray Is 40:31, which I asked Acacia to write out for him as God's promise. Those who wait on the Lord will renew their strength. . Pray that his heart would not give up as he faces uncertain weeks of complete dependence. Pray we would be able to keep him alive. His parents face a long course and a huge expense, and would be grateful for your prayers. Pray that Patrick would once again run and not grow weary, walk and not grow faint.

Friday, November 15, 2013

This is Daniel, looking feisty on his final day with us. When he was admitted 58 days ago, he was hours from death. His mom had defaulted on her own care and seemed completely unable to deal with his AIDS. I agreed to pay his hospitalization costs from our Needy Children Fund, never guessing how long he would stay or how expensive it would be. He was so malnourished and had so many infections. As we started to pull him out of the TB dwindles, he had a reaction to anti-retrovirals that meant we had to stop them. After nearly two months he is finally off oxygen and gaining weight. But the real story is his mom. Daniel saved his mom's life. Because over these two months she slowly came to accept her diagnosis. To allow herself to be helped. To resume her own treatment. In the last two weeks I hardly ever found her without her Bible open on her lap. She found life. I don't know how long Daniel will survive, but I do know his hospitalization was worth every shilling. Two lives were impacted, and I'm grateful for that.

Jonah continues to improve, very slowly. His spine is now stable, and he can be wheeled out into the sunshine. His mother came all the way from Samburu to this place where she knows no one and barely speaks the language of Swahili. She is brave. I am afraid Jonah is blind since his near-death in one of his operations. But he definitely hears, and stops his restless moaning when I talk to him. Jesus made the lame walk and the blind see. Jonah needs that kind of miracle. Kijabe and the Needy Funds have kept him alive and shown him love, putting him in the place where he can wait for the angel to stir the water, for the healer to pass by.

We've had a photography team at the hospital documenting stories like Daniel, Jonah, and this cute 4 year old who was brought to our outpatient Maternal and Child Health clinic Thursday. He is severely chronically malnourished, with very stunted growth due to his mother's inability to feed him enough every day. But here he is having the time of his life seeing his face in the camera. A kind pastor in his town brought him in for care.

Lastly, another vulnerable child, this one a refugee from the largest refugee camp in the world located in Dadaab, Kenya. The NGO's that work there send kids like this to Kijabe for diagnosis and treatment. I believe she has a genetic dwarfism syndome, something that is not easy for a family with seven other children to deal with in a refugee camp located in barbed wire fences in the desert.

So many children who live with too little care, space, food, medicine, opportunity. So many who dwindle without resources or care for too long, and come to us too late. But these four were helped, by our Needy Children's Fund, the Orthopedic Vulnerable Patient Fund, a local Kenyan church, and the UNHCR and other NGO's.

Thank you to all who have donated in the last month. The income and expenditure when I checked on Thursday were almost exactly matched. God knew our needs. I just keep spending the donations on these kids as fast as they come in, knowing the more we help, the more will be provided. THANKS.

Our Paeds department had quite a week. We are supposed to have 3 full time doctors, which includes one husband/wife pair who split the job 60/40. One of the three dropped out with preterm labor and between that and her upcoming maternity leave will probably miss 6-7 months. We are all terrified that work will push her to deliver early, and committed to going the extra mile to cover with just two instead of three. So every day has a bit less margin, a bit more push. December looks even more stressful because of the way leaves were planned, but I had hoped for a pretty stable November. Then on Monday my remaining colleague was feeling sick, so he went home early with abdominal pain. I wondered with his wife about appendicitis, but he didn't think he was really that sick. By Tuesday morning his appendix had ruptured and he was in emergency surgery. Thankfully we have good surgeons and immediate attention and he will be fine, eventually. But he's out for the indefinite future and so is his wife (mostly) to care for him, though she was able to work for the afternoon on Friday she will miss about a ten day stretch as well. I was running around the hospital on Tuesday while they were in the theatre, just thinking about making it through the day post-call and Scott's Birthday with a small party planned for the evening, while trying to take care of all the patients on the general floor, the ICU, the NICU, delivery rooms, casualty, outpatient, private . . it gets a little crazy.

We watched part of the "Home Alone" movie at our last class night, and Julia surmised that evening that we should call Paeds "Work Alone".

But over the course of the day, I realized how NOT alone I really am. As soon as I heard about my colleague going into surgery I texted the three clinical officers whom I had given an admin day "off" and they got out of their car and came right back to work. My RVA nurses rearranged that clinic. My friend and colleague in Nairobi who usually comes out to work and take call about 3 days a month called to say she was clearing her schedule and would come from Weds to Friday morning. A family medicine doc in casualty will help for three days next week, while his casualty work is done by another family medicine doc. Ironically I had finagled a way to get Scott off for 24 hours so we could spend an overnight together at a nearby resort for his Birthday (a few days late) on Thursday night. I wasn't sure until the last minute we could pull it off, but we did. I ended up back in for an ICU admit almost as soon as I got home, but it was a good evening/morning respite, it really felt like a true rest.

I confess I am tired. The sadness of some cases pulls my heart down, the endless press of work drains me, the feeling that there is no one to share the burden feels too hard.

But the truth is, my hope is not in my colleagues, in fairness or work, or in control of my schedule.

My hope is that I'm here serving a God who knew about the preterm labor, the appendix, leave schedules, and everything in between. A God who allows Sabbath, a 1 in 7 rhythm of true rest that is more and more necessary, and does not require apology, the harder the other six days get. It's November 15, and I've only had one full calendar day out of the hospital this month. I'm hoping for a couple more towards the end, asking God to provide.

In the moment when illness strikes, when admissions roll in, when patients crash, when someone says they can't help with something, when unforeseen circumstances press down, I find out my heart-size. A large heart absorbs the stressful circumstances and answers with grace. A large heart listens to each new plans-fallen-through and does not despair. A large heart is not self-protective, and always has room to pour love onto sadness.

My heart is not large enough for this task. But this verse jumped out today from Psalm 119: 32 "I will run in the way of your commandments, when you enlarge my heart." This is the same phrase used of Solomon, whose wisdom had to be accompanied by this character of large heartedness for his decisions to bless many. Immersion in God's word, running in the way of His commandments leads to a largeness of life that is the way I want to live. No counting the bitter hours of who does what, but a generous spirit of service with joy.

So that's my prayer this month, a prayer that the paucity of hands-on-deck will be compensated by a largeness of heart that lets me approach changes in plans with courage and peace. That lets me react with grace to each new stress and push. Please pray that for me.

Friday, November 08, 2013

The burning bush represents the impossible presence of God, and when you see that, you have to take off your shoes.

And that happens in the grief, when a teenager meets Jesus, when a mother is comforted, when we bow in desperate prayer.

It also happens in awe.

So to complete the story of the week, I spent four hours in the hospital this morning in meetings. Not the usual choice for holy ground. The first was the Neurosurgery Audit, where we discussed the last two months of admissions, deaths, infections, new procedures. The Albrights are inspiring people, working way too hard to care for ever increasing numbers of children. Kijabe sees about 250 spina bifida patients a year, ten times more than even the busiest neurosurgical services in America, with a fraction of the resources. And they are doing research on new surgical techniques, publishing scientific papers, and training Kenyan doctors. Inspiring.

From there to a meeting with the Medical Director, Executive Director, Head of Engineering, Head of OB, and me. To propose an expansion of our nursery and maternity space to meet demand. Mardi had made a proposed drawing. Only the Executive Director wanted to think bigger. To have new construction, new space, better facilities, and double the capacity. Again inspiring, because this has real potential to impact child survival.

And from there to a meeting of the BKKH (Bethany Kids) team, surgeons and nurses and administrators who care for children with birth defects and disabilities. We discussed how to not just train surgeons and send them out to Madagascar, Ethiopia, Sierra Leone, Rwanda, Tanzania, Uganda . . but to also support all the other services needed for kids there, to multiply what is happening at Kijabe. A lot of brainstorming and philosophy and really good stuff. Holy ground.

So in the midst of the losses, it is good to see that we are ever improving services, ever increasing hope. To be reminded of the 20 that go home cured for every one who dies. Of the amazingly dedicated and talented people I work with who are pouring their lives out for kids and for Jesus.

Thursday, November 07, 2013

I had just walked out of the morning's monthly staff meeting when my pager went off, and I hurried to the HDU knowing it would be Vincent. He had been vomiting, cold, listless, with abdominal pain through the night I had heard from the on-call doctor, worse than I had left him, but in the early morning hours told the nurse he was hungry. His mother called the staff over an hour later, alarmed, because he was no longer responding. I walked in to find him gasping in the way that people do as they die, pulseless, with the large unmoving pupils of the brain dead. He was gone. That gasp was his last, and as I watched the heart monitor petered out to a flat line. We had long before decided that we would put every effort into his fluids, medicines, oxygen, feeds, and wound care. But we would not do CPR. The low-likelihood of helping high-pain violence of it would have been grotesque in this circumstance. Vincent's suffering was over, even as we gathered around his bed stunned, and then held on to his shaking, weeping mother, he was free. Free of TB and pressure eroding his paralyzed body. Free of the monitors and hospital. Free of our failed help.

Two things made this morning bearable. First, a conversation with the nurse a few minutes after he died, as we reviewed the course, his treatment, what could have gone wrong or been done better. "Did you know that Vincent prayed to receive Jesus last week here, as did his mother?" No, I didn't, but evidently another nurse had been sharing Jesus with them even as she cleaned his wounds. Second, the assurance that we had done everything possible, there was no treatment we held back. We didn't just move him to a corner to die, we kept open the possibility of a miraculous reversal right up to the last minute.

I wish we had seen the Fall-in-reverse, the resolution of disease that we long for. I was reminded by others later that we were discharging 4 other kids who had been healed, and many more the week before. Most kids do get better, most of the time we are witnesses to improvement. But Vincent's body was so weak, so spindly, so ravaged, so destroyed, the path God chose for him to healing was through the valley of the shadow of death, straight to the table prepared. I do not regret the all-out effort to keep him alive for two weeks, which enabled him to experience the hands and heart of Jesus in those who cared for him, to encounter the living Christ. I wish he had not suffered such pain or his mom such loss, but I know that he met Jesus in his suffering, and pray she does too.

Still it was a hard day, moving through the ward, back and forth to clinic, with sorrow in my heart.

Then in the mid-afternoon I went to nursery where we were sending a baby for admission. Simon, the little baby who was in ICU for weeks after multiple surgeries and chest tubes to repair his congenitally non-functional esophagus and trachea, was still there. His faith-filled mom is always content, hopeful, patient. She greeted me warmly. We have spent more time together over Simon than most people in her life. His last chest tube had come out a couple days ago, and he is finally doing well after weeks of nearly dying. I think she could sense that I needed to touch hope today. "Do you want to hold him?" she asked. I'm not sure any mom has ever asked me that. She gently scooped him up in his blanket and handed him to me. Not to evaluate, just to enjoy, mom to mom. It was beautiful. Nothing speaks hope more clearly than a one-month-old who has survived against extreme odds, and is only a short step away from cure.

I tried to get Simon to smile as he chomped his pacifier. I'm sure I smiled. A lot. He was the perfect reminder that God is at work in healing at Kijabe, in spite of the morning with Vincent, there is much good we can still do.

Wednesday, November 06, 2013

Vincent (see post below) pulled through today, barely. Overnight his breathing became labored and he was moved into our 3-bed High Dependency Unit (the level of care between the general ward and the ICU) for high flow oxygen and monitoring. Alarmed by his sleepiness and cold skin this morning I asked the nurse to take his blood pressure: 60/20. Yikes. Fluids, pressors, warmth, antibiotics, prayer and by afternoon he was up to 85/55 and sipping some milk. He just teeters on the edge of fighting the bacteria in his bloodstream and the despair in his soul.

The HDU is a 3-bed unit of excellent care too late. Vincent with his paralysis, chunks of missing flesh, raging infection, all most likely from a disease that was curable for the first few years of gradual symptoms. Little A in the middle whose minor skin pustule turned into a massive flesh-destroying infection, over a matter of a few months eating its way through his side, his kidney, his spleen, his intestines. Perhaps if he wasn't an orphan, living in a remote corner of Kenya, he might have had definitive care in time to save his life. His last surgery revealed we are losing this battle though, and his care is now designed to make him comfortable until his inevitable death. And on the other side Jonah, still pulling for a miracle, fractionally more awake day by day.

Some days, the burden of sorrow just weighs too much. My tough can-do wavers at a kind face bringing tears. The stress of complicated ICU patients, these three heartbreaking HDU patients, the myriad of the malnourished and seizing on the general floor, and the steady flow of outpatients needing assessment or reassurance or more wisdom and insight than I can muster, drains me.

But in the midst of all this a few doses of hope.

First, we had a lovely graduation ceremony yesterday for two Paediatric Surgeons completing their fellowship. Dr. Situma will return to Uganda where the ratio of surgeons to patients is even lower than Kenya . . note that all three boys who got too little care too late had problems that were partially surgical . . . and Dr. Lebbie to Sierra Leone where he will be the first and so far ONLY paediatric surgeon in the country.

The spiritual as well as the medical maturity and excellence of these two men was evident in their speeches, and in contrast to so much of what passes for success in Africa. Really inspiring.

And then I found Acacia and a classmate volunteering to serve meals on the Paeds ward in the evening, and came home to dinner with Jack and three friends from his soccer team, great guys. These are the next generation of hope, and they lifted my spirits.

Tuesday, November 05, 2013

I am going to be politically incorrect and use real names, because these are real people.

Jonah is an 8 year old from Samburu country, who came here on a mission flight in a desperate attempt to save his life. He has tuberculosis of the spine. TB is treatable, and his caretaker who came coughing out the disease is much better. But Jonah's spine was perilously bent, his nerves stretched, his blood vessels compromised. Drs. Muchiri and Mara planned his surgery while our team initiated TB treatment and nutritional support. His first surgery was aborted when his blood pressure dropped, his second allowed most of the infection to be drained out but was aborted when his heart stopped temporarily, and the third finally allowed him to have his spine stabilized. His little brain took a hit, but over the last week he's been opening his eyes and moving his hands. Today I transferred him out of the ICU. Small victories. A recovery would be a miracle. But we can ask for a miracle. I have learned only one word of Samburu: "Suba!" which I say loudly many times a day hoping for a response.

Dr. Mike Mara is pulling for this kid with skills, funds, and prayer, and his hope is inspiring. Here he is greeting Jonah last week in ICU post-op, along with Jonah's little Samburu friend with a hip infection who came on the same plane.

Back home, the village women held a fundraiser to contribute to his care.

Please pray for Jonah.

And please pray for Vincent, who we believe has the same disease. Only he is 15, and his was even more advanced than Jonah's by the time he came. This is his spine MRI courtesy of Dr. Sarah Gessner. Note the folding bend in the top right. It should not be there. His spinal cord is crimped, and he is paralyzed.

Vincent was a normal kid for many years. He had some prolonged illness when he was 4, but eventually ended up on TB meds. Within two months he was so much better that his parents thought that was enough. But TB requires prolonged treatment. It wasn't enough. Vincent's mother began to notice a hump in his back when he was in 6th grade. By 7th grade, his legs were getting weaker. By 8th grade, he could only walk with a stick to prop up his dragging limbs. By 9th grade, he had to go to school in a wheel chair. By August this year, his paralysis and time in the wheel chair forced him to drop out of school. By October, his hips and legs were eroding as he stayed too long unable to move. His mother took him to the best hospital around, which said there was nothing to be done, unless she wanted to try coming to Kijabe. She went home for two days to organize and ponder her terrible choice: let her son die, or travel across the country with him leaving her other four younger kids to depend upon the kindness of neighbors for survival.

She came to Kijabe, where Vincent's horrific wounds were assessed by two surgical services and found to be incurable, particularly in view of his sullen withdrawal. We found him on our ward, reeking, with thick wool blankets pulled over his head. What teenager wouldn't be depressed to be paralyzed, with his body decaying around him? My colleague and I are both mothers of boys this age. We decided to ask for another miracle. To treat his depression and malnutrition, to clean his wounds and see if there was any spark of hope left in his heart. Today he nearly died. His wounds are so infected we had to put him on a course of antibiotics that will cost about $600. The odds of his survival are slim.

But just when it seemed prudent to give up, to not prolong suffering . . a flock of Australian nurses appeared in his room today. Teaching wound care. Thoroughly debriding and cleaning.

What are the odds that these angels would miraculously materialize at this moment?

So we have not yet given up hope. But hope is ethereal, easily vaporized in the hard reality of Vincent's life. Please pray for him to choose to live. Please pray for us to witness the power of God bringing impossible healing in this boy.

Sometimes I have to admit that I hesitate to hope. Hesitate to ask for prayer for two boys who may not be able to breathe much longer, let alone sit, or walk. Hesitate to draw attention to two cases that will most likely end in sorrow, as if that would make God look bad. So I can only say that while they are in my care we will do our best to give space for God to work, to speak words of truth about their worth, to trust that whether God heals them on earth or in death they will be eternally running in glory.

For seven hours yesterday, I stared at a computer screen, squirmed in my chair, tried to block out the incessant clicking of neighboring keyboards - and answered medical questions at the incessant rate of one per minute. I know a lot of medicine. I answered questions ranging from rabies to rashes to radiology, from newborns to geriatrics, from psychiatry to sarcoidosis. And by the end, I was spent.

But today, I want to take a moment to give thanks.
I'm thankful I was healthy, focused, rested, well-fed.
I'm thankful there is an international computerized testing center in Nairobi.
I'm thankful for the prayers of many friends.

And on the way home I saw a spectacular rainbow, reminding me of God's covenant promises, of His love and faithfulness. And it made this little exam pale in comparison...

A few emails and comments have alerted me to the fact that I often fail to give follow-ups after asking for prayer. So here are the answers to a couple questions today, and some bonus points as well:

1. Scott lived through the strenuous and stressful exam. He won't know if he passed for two more months. It was exhausting. Thanks for praying.
2. More importantly, Dr. Travis Johnson finished all his chemo and last week he had the great news of a clear CT scan. We are so thankful for the flood of prayers that carried his family through the last six months of nausea, weakness, and the stark reality of risk. He is now a cancer survivor, which means for the next five years he will be closely monitored. But all is well.
3. Our Burundi Team finally arrived in Kibuye last weekend. After two years working together in Kenya, meeting with WHM and deciding on Burundi, applying, raising support, packing containers, speaking, traveling, then nearly a year together in France for French study and three months in another area of Burundi for Kirundi study . . . drumroll . . . they have moved into the village where they will staff a hospital and teach medical students. Do pray for them to establish strong relationships and healthy boundaries as they work on house construction supervision, and plan to begin full time medical work in January. Meanwhile the Bonds are studying French and recruiting for the Bujumbura branch of this work.
4. Caleb continues to need healing for his knee injury, but with admirable spirit plows on. He has to pass a swimming exam today which with enough tape and pain tolerance he hopes he can do. Luke has applications in to about a dozen or more med schools, so you can pray for God's provision and guidance in that process.
5. Our South Sudan Team is dispersing for rest and home ministry soon, and we continue to pray that the Massos will have the support they need to return in January, and that God will raise up new leaders and new team members to bless the people of Mundri.
6. New team members on the Bundi team have survived a disease-ridden first couple of months, and eagerly await the next influx of colleagues. The spiritual and physical battles there never let up. Pat in Fort Portal could not get travel visas to the US for the two young orphan girls she has guardianship of so needs prayer for wisdom and perseverance as she faithfully continues to serve without the benefit of that break.
7. Josh and Anna Dickenson were wed, and true love is in the air elsewhere, so keep tuned for more announcements.
8. Bethany agreed to RVA's request that she extend her counseling ministry from 3 months to 2 years, hooray. The Maras are hosting a team of photographers to connect the church to the work of Kijabe hospital, and working through difficult issues with inadequate staff in the orthopedic department.
9. In Nairobi, our team continues to reach out to the community accused of the Westgate attack and the community of the victims. This team is focused on language learning right now and could use prayer for Swahili to flow.
10. To make a complete top ten, we thank God for the spiritual hunger among students here at RVA and especially our own. And we are thankful for fellowship and community in spite of demanding, challenging, unending work at Kijabe Hospital.

Sunday, November 03, 2013

Perhaps the best analogy would be the Red Sea blocking one's exit, with murderous armies behind and the Promised Land distant and inaccessible.

On Monday Scott has to sit for an all-day 8 to 5 Family Medicine recertification exam. He'll drive into Nairobi today to stay at a hotel near the Prometrics computerized testing center. The last one he took was ten years ago. He is a fantastic physician, can save your life and cure your malaria, manage your ventilator and life support, treat your diabetes or hypertension, deliver your baby by Caesarean section or suture your wounds. But he hasn't ever touched the last fifteen new variations of diabetes medicines, and he thinks in tropical medicine differentials more than in obesity and over-indulgent lifestyle differentials. After two decades practicing medicine where most of the world's needs occur, our skills sets have diverged from the US standards. For the last few days he's been at his desk, working through a practice test that is designed for fresh-out-of-residency young doctors, and trying to read up and prepare. Family Medicine is a fantastically broad area of expertise, and ten years is a long time since taking this test. The questions are intensely specific and tricky. He is sensing the impassable sea.

Would you please pray for him in your congregations on Sunday, and as you think of it on Monday? Pray that he would not fear defeat, that a way would open, that he would call to mind the thousands of facts that are in his brain, that he would see God's mercy leading him to pass.

Pray that God's glory would be shown in allowing him (and soon me in Paeds) to maintain licensure as we serve here in Kijabe, Kenya.

(And you can pray for us too, I'm on call today and tomorrow and working pretty intensely these days, so a ripple of single-parent-time is not without stress too.)

Friday, November 01, 2013

What would you pay to save this baby's life? A thousand dollars sounds pretty steep in Kenya, more than the annual per capita GDP, but a drop in the bucket many places. She was born prematurely, and survived for a couple weeks in a local hospital. But as the days wore on she became sicker and sicker, and when her twin died, her distraught parents scooped her up and got in a taxi to Kijabe. She arrived on death's doorstep. I got the call in nursery as I was walking out the door that there was a baby in MCH clinic, did we have an incubator? No, I said, we'll have to send her on to Kenyatta. We were running at 150% or more of capacity and taking on another baby would compromise the survival of those we already had.

But as the visiting resident who was staffing the clinic worked on carrying out the plan we had made over the phone, she called back to ask some questions about the logistics of an ambulance. These parents had nothing with which to pay for one. I was at the end of a stressful day and scrambling to get dinner for guests. THANK GOD it was one of those times the Spirit just kept me unsettled. I had no peace about the decision to send this baby on to the national hospital. It sounded like she would die on the way. So I called the resident back with a plan to squeeze her in without an isolette, using a crib and a heater, and hope for the best. I can't explain the internal battle but I knew we were supposed to keep this baby.

That weekend she became much worse, and my colleagues took her to the ICU. I thought it was hopeless. She was on life support for six days, battling a nearly fatal and overwhelming infection. We fought back with the strongest antibiotics, and the kind of medicine and monitoring only available a few places in Africa. This little twin, a deep green color of jaundice, skinny and losing her grip on life, pale and with barely the strength to keep her heart going even when we took over the breathing, teetered on the brink for a week. But day by day her vital signs became more stable. My team was fighting to save this one, particularly as a twin when the other had died. They had more hope than I did.

Eventually she came back down to the nursery, and we gently helped her get to the point of feeding, and then of breathing without any oxygen. Today she's going home, having reached normal newborn size after almost a month of life.

She is cured.

Her parents' national insurance card payed about a third of the bill, and they were able to bring about $250 which is 3-4 months' salary for the average citizen. That left about $1000 still to be paid.

Thanks to several recent generous donations, our Kijabe Hospital Needy Children's Fund was able to step in and pay the bill. Which means that baby M can go home with her mother, who was a hair's breadth away from total bereavement. Which means that we can sustain low cost care and offer the same services to the next baby.

Though this is only a thousandth of the million-dollar-baby story . . the themes are similar, only our story has a happier ending: a fight against the odds, an initial reluctance, a growing wonder, the beauty of strangers growing in relationship, victories, redemption, dilemmas, and loss. Thanks to all who helped baby M survive, and pray that we can stay in the ring for the next one and the one after that. We get beat up pretty often. But today we're celebrating a victory.

Our Mission

who we are

paradox:
1. something that combines contradictory features or qualities.
Life in Africa is full of contradictions - the beauty and pain; the abundance and the poverty; the joy and the sorrow.
Our lives, too...dying that we might live; strong in our weakness; sinners yet saints.
2. a "pair of docs"